Patient’s Profile
Name: n/a
Address: n/a
Age: 40 years old
Sex: Female
Chief Complaint: Dizziness, mild to moderate headache, edema
Religion: n/a
Occupation: n/a
Nursing Health History
History of Present Illness
Patient was admitted on April 5, 2020 in the emergency room and she was at 38 weeks age of gestation. She had
complaints of dizziness, mild to moderate headache with 5 to 6 pain scale and swollen fingers and mid calves.
Health Assessment
(+) awake
(+) Consciousness
(+) Headache
(+) Edema (+2)
(+) Dizziness
List of Prioritized Problem
Nursing Diagnosis Justification
1. Risk of eclampsia related to pre eclampsia as evidenced by Bp of Patient has high bp of 160/100 and is experiencing
160/100 and protein urea plus 3
2. Fluid Volume excess related to pre eclampsia as evidenced by Edema of plus2 on mid calves and swollen fingers
edema over mid calves
Diagnostic tests
Blood test:
CBC was done to monitor overall condition of patient. CBC results came out showing that the patient has normal blood values.
Serology:
NURSING DIAGNOSTIC LABEL: RISK OF ECLAMPSIA
Assessment Explanation of the Objectives of Care Nursing Rationale Evaluation/Criteria
Problem Interventions for Evaluation
S Risk for eclampsia Goal: Dx >Patients remain
> 40 y/o because of the high To reduce blood normotensive
> “ Nahihilo po ako” blood pressure of pressure to normal >Check FHR >Helps evaluate throughout
160/100. Now and reduce protein manually or fetal well being.
O patient is urea thereby electronically as >Patient alters
>Positive facial experiencing reducing risk of indicated activity level as
grimacing symptoms of pre eclampsia condition warrants
>160/100, right arm eclampsia which >Report signs of >Immediate
sitting position include dizziness, abruption placenta attention and
>104 bpm, radial, +1 edema and pain. intervention
regular bilaterally increases the
equal References: likelihood of a
>22 cpm,regular Nursing Diagnoses: positive outcome.
> temperature of Definitions &
classification 2018-
36.9 C 2020(Vol. 11). (2018).
>Evaluate fetal >Reduced placental
New York: Thieme. growth; measure functioning may
progressive fundal accompany PIH,
Nursing diagnosis LTO: company growth at resulting in IUGR.
>. Risk of eclampsia >After 1 week of each office visit or Chronic intraurine
related to pre nursing periodically during stress and
eclampsia as intervention, the stress home. uteroplacental
evidenced by Bp of patient will report a insufficiency
160/100 and protein decrease in the pain decrease amount of
urea plus 3 and dizziness felt fetal contribution to
and will report less amniotic fluid pool
to none presence of
edema. >Institute bedrest >Improves venous
STO: with patient in return, cardiac
>After 15 minutes of lateral position. output and
health teaching, the renal/placental
patient will perfusion
enumerate 3 foods
she should eat to >Prepare for birth of > If conservative
improve her fetus by caeseran treatment is
condition delivery, labor when ineffective and labor
>After 15 minutes of severe induction is ruled
health teaching, PIH/eclamptic out, then surgical
patient will condition is procedure is the
enumerate 5 stabilized , but only means of
perceived effective vaginal delivery is halting the
management not feasible hypertensive
techniques problems
>Within 24hrs of
nursing
interventions, the Tx: > If BP does not
patient will rate her >Give respond to
pain as 2-3 antihypertensive conservative
drugs such as measures, short
hydralazine PO or term medication
IV so that diastolic may be needed in
readings are conjunction with
between 90 and other therapies.
105mmHg. Begin Antihypertensive
maintenance drugs work directly
therapy as needed. on arterioles to
promote relaxation
of cardiovascular
smooth muscle and
help increase blood
supply to different
organs.
>Side effects such as
>Check on BP and tachycardia,
side effects of headache, nausea
antihypertensive and vomiting and
drugs . Administer palpitations may be
propanalol as treated with
appropriate. propranolol
>Provides precise
>Check for invasive picture of vascular
hemodynamic changes and fluid
parameters volume. Prolonged
vascular
constriction,
increased
hemoconcentration
and fluid shifts
decrease cardiac
output.
Ed:
> Present >Decrease in
information to placental blood flow
patient concerning results in reduced
home assessment or gas exchange and
noting daily fetal impaired nutritional
movements and functioning of the
when to seek placenta. Potential
immediate medical outcomes of poor
attention placental perfusion
include a
malnourished, LBW
infant and
prematurity
associated with
early delivery,
abruption placentae
and fetal death.
